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1、出血性腦卒中hemorrhagicapoplexy中南大學(xué)湘雅醫(yī)院神經(jīng)內(nèi)科谷文萍WenpingGu,MD.PhD.NeurologyDepartment,XiangyaHospital,centralsouthUniversity腦出血cerebralhemorrhage腦出血cerebralhemorrhage是指原發(fā)性非外傷性腦實(shí)質(zhì)內(nèi)出血80%以上由高血壓性腦內(nèi)細(xì)小動(dòng)脈病變引起,固又稱(chēng)高血壓動(dòng)脈硬化性腦出血發(fā)病率高，占全部腦卒中20％—30％Hypertensionisthemostcommonunderlyingcauseofnont
2、raumaticintracerebralhemorrhage病因與發(fā)病機(jī)制etiopathogenisisandpathogenesy高血壓性腦內(nèi)細(xì)小動(dòng)脈硬化高血壓性腦動(dòng)脈硬化時(shí)可有腦內(nèi)細(xì)小動(dòng)脈透明變性、纖維素樣壞死，病變管壁在血流沖擊下形成微動(dòng)脈瘤hypertensionappearstopromotestructuralchangesincludinglipohyalinosis,fibrinoidnecrosisandmicroaneurysmformationinthewallsofpinetratingarteries,pred
3、isposingthemtointracerebralhemorrhage.導(dǎo)致腦動(dòng)脈管壁薄弱的其他疾病血液系統(tǒng)疾病腫瘤卒中原因不明病理pathology多為腦動(dòng)脈深穿支破裂所致豆紋動(dòng)脈最為常見(jiàn)，次為丘腦穿通動(dòng)脈、基底動(dòng)脈旁中央支多發(fā)于大腦半球基底核區(qū)，次為腦葉、腦干和小腦Mosthypertensivehemorrhagesoriginateincertainareasofpredilection,correspondingtolong,narrow,penetratingarterialbranches.Theseincludethec
4、audateandputaminalbranchesofthemiddlecerebralarteies(42%);branchesofthebasilararterysupplyingthepons(16%);thalamicbranchesoftheposteriorcerebralarteries(15%);branchesofthesuperiorcerebellararteriessupplyingthedentatenucleiandthedeepwhitematterofthecerbellum(12%);andsomewhi
5、tematterbranchesofthecerebralarteries(10%).出血可直接破壞腦組織血腫擠壓周?chē)M織，引起腦組織水腫、顱內(nèi)壓增高，嚴(yán)重可引起腦疝臨床表現(xiàn)clinicalmanifestation>50歲高血壓患者(hypertensivepatients)突然發(fā)病,迅速達(dá)高峰(suddenlyonset)全腦癥狀(globalsymptom)局灶癥狀(focalsymptom)臨床表現(xiàn)clinicalmanifestation殼核出血（putamenhemorrhage）內(nèi)囊外側(cè)型出血，為高血壓性腦出血最常見(jiàn)的類(lèi)型丘腦
6、出血（thalamichemorrhage）腦葉出血（lobehemorrhage）腦干出血（brainstemhemorrhage）中腦出血（midbrainhemorrhage）腦橋出血（pontinehemorrhage）延髓出血（medullaoblongatahemorrhage）小腦出血（cerebellarhemorrhage）腦室出血（cerebroventricularhaemorrhage）輔助檢查laboratoryfindings頭顱CT(CTscan)頭顱MIR腦血管造影(cerebralarteriography
7、)DSA、MRA、CTA腰穿腦脊液檢查(lumbarpuncture)血、尿常規(guī)、血糖、電解質(zhì)檢查診斷與鑒別診斷diagnosisanddifferentialdiagnosis大于50歲，多有長(zhǎng)期高血壓病史(oldpatientswithhypertension)活動(dòng)中或情緒激動(dòng)時(shí)突然發(fā)病(suddenlyonset)頭痛、嘔吐、意識(shí)障礙等全身癥狀(headache,vomitting,impairmentofconsciousness)偏癱、偏身感覺(jué)障礙、失語(yǔ)等局灶神經(jīng)體征(hemiparesis,hemisensorydeficit,
8、hemianopia,aphasia)CT見(jiàn)腦內(nèi)出血病灶(CTfindhematomas)與其他類(lèi)型腦卒中、腦外傷后硬膜下出血、內(nèi)科疾病鑒別治療treatment控制腦水腫、顱高
